T

HE last quarter of a century has been a golden age of medical discovery. One disease after the other, hitherto ranked in the highly fatal and unmanageable class, has yielded its terrors to the weapons of medical science. Medicine is rapidly emerging from the shadow of empiricism and becoming an exact science in the same sense as bridge-building and tunnel-construction.

The soupy infusion of foxglove, used as a heart stimulant during the nineteenth century, has been superseded by a standardized tincture, thoroughly tested by experiments on the cat's heart. The "shotgun prescription," meaning a fancy conglomeration of drugs that cured Mrs. Casey of pain in the back and should therefore help Mr. Jones's lumbago, is now a back number; it has been replaced by specific serums, vaccines, and hormones. The old-fashioned diagnosis of "acute indigestion" has been buried alongside the bones of its victims; to-day the tricky appendix is taken out in time to thwart death.

In brief, the old-time mental attitude of the profession, expressed by the statement, "I have found that this prescription hits the mark every time," is entirely out of date. The question now is: "What is the rationale of this method of treatment?"

Great should be the glory of the body of medical men that has so far advanced the efficiency of the healing art. But, as a matter of fact, the public has reacted unfavorably to changed methods of medical practice. In the memory of octogenarians, the prestige of our doctors with the public has never been lower. "Where,

oh, where, is the good old family doctor of bygone years?" is the cry everywhere from an aggrieved public.

Comparisons are sometimes odious. Many folk seem to regard the modern medical man as a deteriorated pigmy of the idolized old-time country doctor. They do not have the same respect for the medical man of to-day as was held back in the nineties. The doctor has changed. The public no longer look up to him.

The arrival of the doctor in the nineties was an event of importance. His coat and hat were handled reverently, and his cane guarded like an emblem of royalty. With due ceremony, the practitioner was ushered into the presence of the sick. Every statement was carefully noted by those present; every order heeded to the smallest detail. When the doctor departed, he was escorted respectfully to the door. Perhaps his fee was only fifty cents and he had to drive ten miles with a horse to earn it. Just the same, he was treated with that respect and consideration that always gladden the heart of a professional man. As for questioning his diagnosis or method of treatment, the family would just as soon seek redress from a decree of the Supreme Court of the United States.

Simplicity marks the welcome of the doctor of to-day. As he rings the doorbell, a voice calls from up-stairs: "Mary, see whether that's the iceman or the doctor."

Mary inspects the doctor carefully, apparently in doubt as to his identity. Not seeing the tongs and cake of ice, she calls up: "It's the doctor."

"Tell him to come up," is the curt command from above.

As the physician enters the sick-room, the occupants eye him suspiciously. If

he could interpret looks, he would read such unflattering messages as these:

"He's entirely too young! I wonder if he knows the difference between a boil and a cancer."

"That looks like a fifteen-dollar suit he has on."

"He acts as if this were the first patient he ever had."

If it disagrees with the preconceived notions of the family, the diagnosis is treated with contemptuous scorn, and the directions as to treatment travel via the time-honored route, in one ear and out the other.

As the doctor departs without his fee, picking his hat and coat off the floor where Mary has dropped them, three voices blurt out in unison: "The idea! Pleurisy! Send for another doctor right away!"

Such is the prestige of the modern doctor!

GLORIFYING THE OLD-TIME COUNTRY

DOCTOR

Who was the old-time country doctor about whom we hear so much? What made him so great? Just what were his qualifications?

The old-time doctor was trained primarily as an apprentice to a practising physician. The student accompanied the practitioner on his rounds, watched his methods of examining the sick, and committed to rote the shotgun prescriptions from which such marvellous results were expected.

In this manner a type of medical practice that amounted to little more than systematized folklore was passed on from one generation to the next. The fundamental principle underlying this form of medical education was that experience teaches; but the experience was that of the individual doctor who was doing the teaching, not of the organized body of the profession.

The student had but one preceptor, whose example he followed religiously. Good, bad, or indifferent, the experience and prejudices of that single teacher were passed on to the future country doctor as his main stock in trade.

It is true that the term of apprenticeship was supplemented with a course of college lectures. But these desultory di

dactic lectures bore but slight resemblance to the highly organized medical curriculum of to-day. Twenty years ago America had more medical schools than all other countries combined; but what she had in quantity she lacked in quality.

The eighties and nineties were the Dark Ages in the training of America's doctors. An apprenticeship with a competent practitioner of medicine has definite advantages; but there is little to be said in favor of a perfunctory course of instruction at a third-rate college.

The renaissance in medical education did not begin until 1907. At that time, the American Medical Association, the representative body of America's physicians, investigated the one hundred and sixty colleges then existing and found the most deplorable conditions. In some institutions one teacher constituted the entire faculty. By word of mouth he attempted to teach anatomy without dissection. The blackboard took the place of the chemical laboratory; a stuffed dummy, the living patient; and a few graceful gestures of the hand, the steps in the removal of the diseased appendix.

One medical college, in 1905, graduated one hundred and five M.D.s who had never dissected the human body, worked in the laboratory, or been given a chance to see a single patient in the dispensary or hospital.

Doctors are not born such; they are nothing more than the products of a highly specialized education. And the old country doctor suffered a tremendous handicap with respect to the limitations of his education.

I do not wish to detract from the glory of the physician of the eighties and thereabouts. His wits were sharp, his judgment sound, and his heart stanch. He accomplished wonders with his limited equipment. He was a great pioneer.

Most emphatically, however, must one pooh-pooh the idea that, man for man, the practitioner of thirty or forty years ago was a better doctor than the product of to-day. He could not be, for his training was vastly inferior, and his opportunities for advancement less. The modern automobile is a great improvement over the one-horse shay; so is the physician of to-day over the old-time country doctor.

THE HIGH STANDARD OF MEDICAL

EDUCATION TO-DAY

When the appalling status of medical education was revealed by the investigation of 1907, the American Medical Association came down on the one hundred and sixty medical colleges "like the wolf on the fold." As the result of this wholesale housecleaning, there are to-day just eighty medical colleges, half the number of two decades ago.

The medical curriculum of to-day sets a very high standard. Before he is permitted to matriculate, the candidate for the degree of M.D. is required to graduate from high school and obtain the equivalent of two years of college education. The four years of medical instruction that follow contain many crowded hours.

If you happen to visit the wards of a hospital connected with a medical college on a Sunday or holiday, you may see some white-coated young men taking histories and examining patients. They are senior medical students trying to catch up with their overcrowded calendar.

The doctor of to-day is not only far ahead of the old-time country physician in fundamental training; his varied experience during his one or two years of internship gives him a direct contact with disease and the methods of treating it that was altogether impossible during the apprentice period of medical education.

Altogether, the doctor of to-day is head and shoulders above his predecessor of the eighties and nineties. How, then, has it come about that he has lost caste?

THE PASSING OF THE GOATEE

Before the days of diphtheria antitoxin, the kind-hearted physician would sadly tell the parents: "This is diphtheria. I am very much afraid you will lose the child." Then he would sit patiently by, waiting to detach a membrane with his finger, or give whatever simple aid the limited state. of medical knowledge of that time per'mitted. If the case was serious, time meant nothing to him. He would hitch his horse to the lamp-post and send a small boy around to the office to tell the waiting patients that he would arrive

when he got there. Gently he would close the child's eyes after the last gasp, and soothingly assure the stricken mother that God's will cannot be denied.

Let us rehearse the diphtheria drama as it occurs to-day. Baby has a sore throat, and so Doctor Modern is called on the telephone. He arrives in a Ford.

Grandma is shocked by the doctor's appearance. Where, oh, where, is his goatee? Can this smooth-chinned, impudent fellow, who looks more like a bank clerk or an actor in a stock company, profess to be a real doctor?

When the doctor looks at baby's throat, he says: "This looks like diphtheria, but I'll have to take a throat culture to make sure."

Then grandma pipes in: "When I was a girl, the doctors knew their business. They didn't have to poke sticks into a child's mouth to find out what's what."

The antitoxin is given. Then, without any patting of hands, soft soap, or bla-bla, the doctor is off.

The child recovers, thanks to the antitoxin. The parents take the recovery as a matter of course, as one accepts a suit that has been dry-cleaned properly.

One day, the garrulous gossip from the next apartment comes panting into the room with a newspaper item. The heading reads: "Child Dies in Five Minutes after Overdose of Antitoxin."

Antitoxin! That's just what Doctor Modern "experimented with" on baby!

Hastily baby is examined and, surely enough, some blotches are found on his skin. Then follows the hurry call for another doctor, and Doctor Modern's monthly statements suffer the ignominious fate of forty per cent of all medical

accounts.

The cold, business-like efficiency of Doctor Modern has failed to impress his clientele. The public demands kind words, soft assurances, and honeyed expressions of comfort; in brief, the personal touch. They want the doctor with the goatee!

Everywhere to-day the conscientious efforts of the physician to cope with disease with the maximum of efficiency and the minimum of bla-bla are met with distrust and suspicion.

An acquaintance of mine in a small town had an attack of appendicitis. The

When the physician makes two calls a day, performs laboratory tests for exact diagnosis, or advises a necessary operation, the patient, in many instances, treats him as if he were a salesman. Oftentimes he directly insults the doctor by intimating that the desire for the fee, not the gravity of the illness, is the underlying reason for "all the fuss."

Never before has the medical profession been more efficient, scientific, or idealistic in its aims than to-day. Nevertheless, its reward from the public for this laudable trend is nothing better than general distrust, forty per cent of unpaid bills, and wholesale derelictions to ignorant quacks. The doctor has spoiled the public!

THE ROCKS OF ALTRUISM

It is a maxim of sound business that every concrete improvement in a product must be accompanied by a splurge of "good-will" advertising; otherwise, the purchasing public would be none the wiser.

Good-will advertising is no part of the programme of the medical profession. This body makes very little effort to inform the public of what it is doing for their betterment. Advertising and publicity in general are naturally repugnant to the medical mind; perhaps they should not be, but they are.

Medicine is a science. The men who are responsible for its advancement are interested in a greater knowledge of dis- ease and improved methods of coping with it. Whether or not the public appreciates their efforts seems to make no difference to them.

Good-will cannot be built up by deeds alone. The achievement must be there, but so also must the advertising. Let the manufacturers of the finest grade of hosiery in the country cease advertising for a few years, and they will soon find very little demand indeed for their prod

uct.

The medical profession is tongue-tied with reference to its own achievements. Much of this medical aphasia is unavoid

able. Advertising by individual physicians is, of course, unethical.

The logical answer to this difficulty would be for the profession to disseminate the knowledge of medical achievements to the public press. But here comes the great impasse. Newspaper editors insist that an item of information must have "news value." The medical man insists that it must be strictly accurate, regardless of its "news value." He will not twist the facts one iota in deference to that great editorial god, H. I. (human interest). Hence, many of the authentic accounts of medical advances find their way to the lower strata of the editorial waste-basket.

Lack of salesmanship is another important factor in the decline of the doctor's prestige. The old-time country doctor started his career in direct contact with the sick, not as a scientific man. Therefore his earliest training was in rubbing the cat's fur the right way. What he lacked in scientific training he made up in tact and diplomacy. He was primarily a good salesman.

The modern doctor is the poorest salesman in the world. A man who devotes his entire attention to the control of disease cannot be expected to master the essentials of expression and impression of which the advertising writers speak so glibly.

A very important factor in lowering the doctor's prestige is the deliberate cheapening of his services by the universal trend toward free medical attention. Whatever is free is not appreciated. Water is one of the essentials of life; but who ever thinks of thanking the engineering and public-health authorities for conveying it safely to our spigots?

In the United States 8,000,000 persons a year avail themselves of free medical service. The class of medical attention given at these clinics is usually of a very high order. How, then, can the practising physician expect to receive any respect, when his services are constantly compared with a form that can be received gratis?

THE REMEDY

The remedy must come either from the doctor or the public. If the doctor is to take steps to correct the conditions that have led to the downfall of his prestige, he

must become less business-like and more human, learn less science and more bla-bla, and cater his advice to the whims of grandma rather than to the inflexible dictates of pathology; in short, he must rehabilitate the goatee and all that goes with it.

However, all vital statistics, to say nothing of common sense, prove that the work performed by the doctor of to-day is vastly superior to that of his predecessor with the goatee. Therefore it is manifestly to the interest of the public to retain the cold, calculating, scientific medical man of to-day and reconcile themselves to the loss of his goatee.

The doctor of to-day is a scientific idealist. He thinks of cancer as an extremely interesting problem in pathology, where the layman can see only human.

affliction and disaster. Frequently, the physician appears cold and unsympathetic. But his apparent lack of heart is only a mask that he wears for his own protection. A man who must perforce witness a dozen tragedies every day cannot take them all to heart; if he did, his calling would soon become impossible. After all, it is not mushy sentiment in the sick-room but cold, exact science that has increased the span of human life by more than ten years.

To my way of thinking, the public has been spoiled by the too easy-going toleration of the medical profession. The remedy must come from the public; otherwise, medicine will slip back into salesmanship. Appreciation of the modern doctor is much better than depreciation.